Reference no: EM133295588
The focus of the SBAR is to develop and report on ONE major issue already identified in the group concept map presentation.
The major issue that was chosen is self-care deficit related to post-op surgery, discharge may need assistance or the patient may need assistance since she lives alone.
The SBAR is to be comprehensive and include:
o Which health care team member(s) you are communicating with (e.g., social worker, dietitian, nurse practitioner, physician, etc.)
o The details you are communicating
o The request / recommendation you are making as the nurse providing care for the
patient/client with rationale for why you are making the request / recommendation
The SBAR is NOT to be a change of shift hand off report.
Case Scenario:
Client Profile :
Kasumi Bai is a 42-year-old female, one day post op total abdominal hysterectomy. Kasumi Bai's primary language is Hachijo, she has a fair understanding of English.
Subjective Data • States her pain level is 4 out of 10 after pain medication is administered • Lives alone • 20 years ago, Kasumi Bai's mother had a hysterectomy resulting in her death 10 days later from surgical complications
Objective Data
• Abdominal dressing is stained with dried dark red drainage • V/S at 1200: T - 37.2 °C, P - 82, R - 22, BP - 130/76, O2 sat - 96 % • Fine crackles audible in lower bases of lung fields • Foley removed at 0600, at 1400 voided 400 ml
Collaborative Care
• Medications o Morphine sulfate 5 mg IV Q3H PRN for pain • V/S Q4H • Activity: Ambulate to bathroom with assistance • Diet: Clear liquids • An incentive spirometer is at the bedside
At 1800 Kasumi Bai states her pain level is 8 out of 10. You take out an ampule labeled hydromorphone 10 mg/mL and administer 0.5 ml